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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701306
Report Date: 12/24/2024
Date Signed: 12/24/2024 04:06:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2024 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20241113165119
FACILITY NAME:MEADOWS SENIOR LIVING, THEFACILITY NUMBER:
342701306
ADMINISTRATOR:SELLERS, ALYSSAFACILITY TYPE:
740
ADDRESS:9325 EAST STOCKTON BLVD.TELEPHONE:
(916) 877-7835
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:160CENSUS: 89DATE:
12/24/2024
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Ashley Melendez, Director of Health and WellnessTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff caused injury to resident in care.
INVESTIGATION FINDINGS:
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On 12/24/2024 at 2:50pm, Licensing Program Analyst (LPA) arrived unannounced to this facility to conduct a follow up complaint visit and deliver findings regarding the allegation noted above. LPA met with the designated staff, Ashley Melendez, Director of Health and Wellness, and stated the purpose of this visit.

On October 31, 2024, the facility self-reported an incident involving Resident 1 (R1) and staff member (S1). The incident occurred when R1 attempted to take a walker from another resident’s room. S1 intervened, resulting in a physical altercation during which R1 fell and sustained injuries. The facility conducted an internal investigation, deemed the fall suspicious, and notified local law enforcement, the Ombudsman, and other relevant authorities.

This investigation consisted of interviews with relevant parties, reviews of relevant documents and an analysis of surveillance footage capturing the incident.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20241113165119
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 342701306
VISIT DATE: 12/24/2024
NARRATIVE
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Surveillance footage from October 31, 2024, revealed that R1 entered another resident’s room and took a walker. At 7:11:49 PM, S1 intervened to retrieve the walker. The video showed a physical struggle between S1 and R1, during which S1 pushed R1, causing R1 to fall backward and hit the floor. The footage contradicted initial documentation in R1’s progress notes, which alleged that R1 exhibited aggression and struck S1 prior to falling.

R1’s care notes from October 31, 2024, described the incident as escalating from aggressive behavior by R1. However, this account was inconsistent with the video evidence.

Interviews revealed that the facility’s internal investigation identified discrepancies between the surveillance footage and the account recorded in R1’s care notes. It was confirmed, through interview, that the video showed no evidence of R1 striking S1 and that the fall resulted from S1’s physical intervention. It was stated that S1 was terminated following the incident and that additional staff training was conducted.

S1’s training records from 2023 to 2024 showed S1 received education in dementia care, de-escalation techniques, and resident safety. Training covered include managing challenging behaviors and minimizing resident-to-resident conflicts. Despite this training, S1’s actions during the incident were inappropriate and directly contributed to R1’s fall and subsequent injuries.


The allegation that facility staff caused injury to a resident in care is SUBSTANTIATED. While the licensee provided adequate training to staff, S1 failed to apply the principles of de-escalation and resident safety, resulting in a preventable injury to R1. The video evidence clearly shows that S1’s physical intervention directly led to R1’s fall and injuries. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Immediate civil penalties were also assessed today in the amount of $500.00. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department.

Exit interview was conducted and a copy of this report was provided along with appeal rights were provided. {2 of 2}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20241113165119
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 342701306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/26/2024
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities:
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations.
This requirement is not met as evidenced by:
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Prior to this complaint, staff member was immediately removed from the facility. Additionally, the Administrator conducted an in-service training for all staff following the incident, which included guidance on managing behaviors associated with dementia.
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Based on interviews, record reviews, and analysis of video footage, staff (S1) pushed
resident (R1) causing the resident to fall back and sustained injuries. This poses an immediate health, safety or personal rights risk to residents in care.
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Per discussion, the licensee will conduc ant in-service regarding elder abuse and proof of the in-service will be submitted to the Department once it is completed. Date of the proposed in-service training to be submitted by the specified POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC9099 (FAS) - (06/04)
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